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A Quick Guide to
Dry
Eye
j a s o n c a l h o u n , o p h t h a l m i c p h o t o g r a p h e r , d e p a r t m e n t o f o p h t h a l m o l o g y, m ay o c l i n i c j a c k s o n v i l l e
Dry eye may not blind your patients,
but moderate or severe disease is
making some of them miserable.
Spot and treat this overlooked
condition in its early stages, and
make a difference for your patients.
A
s a cornea fellow some 30 years
ago, Robert S. Feder, MD, was
shown a cartoon of an elf holding
a watering can. “That was the
model for treating dry eye disease. Water the
cornea,” said Dr. Feder, at Northwestern University in Chicago.
Fifteen years later, not much had changed.
“Doctors said, ‘Take these tears and go home,”
said Giacomina Massaro-Giordano, MD, now
at Penn Dry Eye and Ocular Surface Center,
Philadelphia. “Dry eye was ignored.” Or, worse,
these patients were dismissed as crazy. Indeed,
this was the case with Dr. Massaro-Giordano’s
mother when she complained about her eyes.
But patients who say they have foreign body
sensations in their eyes—or burning, dryness,
or exquisite sensitivity to wind or air conditioning drafts—suffer from a very real condition. Today doctors better understand dry
eye disease (DED), a multifactorial condition
associated with ocular surface inflammation
and tear film hyperosmolarity. There are even
centers, such as Dr. Massaro-Giordano’s, dedicated to its treatment.
Growing prevalence. As the population ages,
doctors will be diagnosing DED with greater
frequency. Though the condition is not associated exclusively with aging, its prevalence
increases with every decade of life over 40. It is
also associated with contact lens use, cigarette
smoking, diabetes, prolonged video display
viewing, and low-humidity environments.
Twenty percent of the U.S. population is
diagnosed with dry eye, said Dr. MassaroGiordano. Still, the disease is very underdiagnosed, Dr. Feder noted. “It is also underappreciated in that you don’t see frank pathology as
you do in macular degeneration or cataract, so
it may be easy to ignore,” said Penny A. Asbell,
MD, FACS, at Icahn School of Medicine in New
York.
Unhappy patients. The more severe forms of
DED have been ranked equivalent to unstable
Miriam Karmel, Contributing Writer
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Causes of Dry Eye
The two major types of DED are aqueous tear deficiency (ATD) and evaporative dry eye. In the latter,
which is linked to meibomian gland dysfunction, lipid
insufficiency may result in increased evaporation and
tear film instability, among other sequelae.3
It’s important to try to differentiate between the
two underlying causes. In many—but not all—cases,
the treatments are the same, said Robert W. Weisenthal, MD, at SUNY Upstate Medical University, Syracuse. Dr. Asbell added that some patients may have
a little of both types. “The reality is that it’s pretty
hard to tell. There’s no surefire test.” Still, you want
to think about findings that point more toward ATD
or evaporative DED because that may alter your treatment, she said.
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Either way, DED will progInspissated meibomian glands.
ress. Chronic inflammation
of the lids from meibomian
gland dysfunction and evaporative dry eye, coupled
with tears that contain inflammatory components,
can further damage the meibomian glands, said Dr.
Massaro-Giordano. Tear insufficiency dry eye, on the
other hand, may point to an underlying autoimmune
disorder. “Over time, that can destroy the lacrimal
glands,” she said.
Consider systemic conditions. A number of inflammatory autoimmune conditions can cause dry eye.
One of the most important objectives of the dry eye
evaluation is ruling out Sjögren syndrome, said Esen
K. Akpek, MD, at Wilmer Eye Institute, Baltimore.
One in 10 patients with clinically significant dry eye
will have Sjögren’s, which puts the patient at risk for
systemic conditions such as lymphoma and major
organ involvement, including the lungs, kidneys, and
liver, she said. These patients often complain of dry
mouth, fatigue, and joint pain. The clinician should
always inquire about these symptoms in assessing dry
eye patients.
Symptoms of concern. Dr. Feder said to beware of
potential underlying conditions when dry eye is accompanied by the following symptoms:
• Fullness and/or tenderness in the superotemporal
eyelid—the area of the lacrimal gland—should trigger
consideration of dacryoadenitis, either postviral or
associated with inflammatory disorders such as sarcoidosis. If a conjunctival granuloma is present, it can
be biopsied.
• Proptosis and/or eyelid swelling may indicate thyroid disease.
• Subepithelial fibrosis in the conjunctiva of an elderly patient should be evaluated for ocular mucous
membrane pemphigoid, with conjunctival biopsy for
immunopathology looking for antibodies to the basement membrane.
Diagnose Dry Eye
Because dry eye disease is hard to diagnose, “What we
need is a metric that says, ‘Yes, you have it. Or don’t,’”
Dr. Asbell said. Ideally, that metric also could distinguish severe from mild cases. She compared it with
HIV, where a blood test confirms that you either do
or don’t have the disease. It can measure viral load
robert w. weisenthal, md
angina in quality-of-life utility assessments.1 “You
may not go blind from it, but it does affect your whole
persona,” said Dr. Massaro-Giordano. Dr. Asbell
added that patients who have significant dry eye “are
not too happy.” It’s a chronic pain syndrome, she said.
“These can be challenging patients to care for.”
Frustrating for physicians. Dr. Asbell noted that DED
can be challenging to diagnose. For instance, when
a dry eye patient reads the chart, she may have 20/20
vision because she blinked before reading, yet she still
says, “But I don’t see well,” said Dr. Asbell. She likens
this to a car with a dirty windshield. Clean it off (or
blink) and you can see through it. However, many of
these patients are not blinking often enough to maintain good vision throughout the day.
A few years ago, Dr. Asbell surveyed ophthalmologists on their perceptions about treatment of dry
eye, and they reported being frustrated, saying that
patients with moderate to severe DED were difficult
to treat. Ophthalmologists wanted more treatment
options.2
Multifactorial misery. DED is also challenging to
diagnose and manage because it is multifactorial. To
better handle patients with DED, the Penn Dry Eye
Center, for example, has a team of experts to address
the range of conditions that might be associated with
DED: a rheumatologist for autoimmune disease; a
dermatologist for underlying rosacea; an oculoplastic
specialist for malpositioned eyelids, which can affect
the tear film; an endocrinologist for the hormonal
component; and a contact lens specialist.
Most ophthalmologists don’t have the extensive
support of a dry eye center to deal with advanced disease. But even mild DED poses challenges. What’s the
best management strategy? Yes, watering the eyes with
artificial tears may provide symptomatic relief. But
before you reach into the sample drawer and say, “Try
this tear supplement,” consider what the experts are
saying about DED.
Diagnostics & Tests
Several diagnostic tests for dry eye
are available, but expert opinion
about their use is mixed.
Dr. Feder pointed out that ophthalmologists are still learning
about the utility of these products
for everyday practice. But, he said,
“if the goal of therapy is to reduce
symptoms, improve function, and
prevent damage, and if you can do
that in the vast majority of patients
for the cost of a fluorescein or
Schirmer strip, you have to ask, ‘Is
it worth the extra expense to buy
equipment and administer a sophisticated test?’” Dr. Weisenthal noted
that even though these tests
quantify what you see, they
don’t alter his treatment
approach.
Here are a few devices
and tests on the market:
Keratograph 5M (Oculus)
and Tear Stability Analysis
System (Tomey). If the tear film isn’t
thick enough or doesn’t last long
enough between blinks, holes appear
in the tear film, causing irregularity
of the surface.
“These two devices assess the
irregularity or regularity of the surface
between blinks,”
Dr. Akpek
Keratograph 5M
said, adding that they’re essentially topographers that can be very useful for dry
eye specialists. She recommended
their incorporation into LASIK and
premium lens implant practices
because they are topography-based
and give good information on
TBUT, in addition to corneal
power, which affects refraction.
RPS Inflammadry dectector
Dr. Asbell called the Keratograph
one of the promising newer devices.
corneal epithelial barrier function,
“That machine has a lot of potential
increased corneal desquamation,
for putting us in the realm of what
and corneal surface irregularity.
we want: minimally invasive objecHowever, the device doesn’t distintive metrics.”
guish dry eye from other inflammaLipiView Ocular Surface Interfertory disorders, Dr. Akpek said. Still,
ometer (TearScience). This device
objective MMP measures may guide
measures TBUT by taking a photo of
treatment decisions. “It tells me
the tear film and looking for areas of
the surface is not healthy and that
desiccation.
the patient needs to be aggressively
It’s used to diagnose evaporative
treated.” The device may correlate to
dry eye, Dr. Akpek said. “Whenever
fluorescein punctate staining of the
we see a dry eye,
cornea, she said.
we apply gentle
Sjö (Nicox). This in-office findigital pressure
ger-stick blood test, which is sent
on the lid margins
out to Immco labs, is designed to
to get meibum
check for novel antisecretion out
bodies that may be
of the glands.
positive earlier than
LIPIVIEW
We look at its
the traditional antiappearance. An experienced ophbody tests. Because
thalmologist can distinguish good
Sjö is very new, it is
quality from bad quality. Although
not clear whether all
LipiView does not evaluate the
insurance companies
SJö
quality of meibum, it gives good
will cover it, said Dr.
information about whether there
Massaro-Giordano.
are adequate amounts of meibum in
TearLab Osmolarity System (Tearthe tear film,” she said.
Lab). This device measures tear
RPS InflammaDry Detector (Rapid
osmolarity, which if too high may
Pathogen Screening). In 10 minutes,
damage the cornea and conjunctithis device delivers a reading on
va. Dr. Akpek said the osmolarity
levels of MMP-9 (matrix metalloprosystem would be a good addition to
teinase-9), an inflammathe armamentarium.
tory marker shown to be
“It’s quicker and less
elevated in the tears of
invasive than SchirmDED patients. Increased
er testing. It can be
MMP-9 activity may
done by a technician.
contribute to deranged
It is reimbursed.”
tearlab
over time. “There’s no equivalent for dry eye disease,”
she said. But there are ways to make a diagnosis.
Listen. You can get a pretty good idea by listening
to the patient and taking a careful history, Dr. Asbell
said. Dr. Massaro-Giordano added, “What sets some
people off doesn’t set off others. It takes a lot of chair
time with patients trying to figure out what makes
their eyes feel better.”
Dr. Weisenthal suggests that physicians ask the
following questions:
• Is your dry eye worst upon awakening? Or does
it get worse as the day goes on? The former suggests
aqueous tear deficiency; the latter, meibomian gland
dysfunction.
• What activities make it better or worse?
• Are you using diuretics or antihistamines? (These
exacerbate symptoms of dry eye and are known to
make dry eye worse, said Dr. Massaro-Giordano.)
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functioning. It is the first-line stain to use in evaluating the ocular surface.
• Lissamine green or rose bengal staining to reveal
devitalized epithelium. Use these stains to evaluate
the ocular surface, not just the cornea, Dr. Weisenthal
said. “If fluorescein doesn’t confirm my suspicion, I
do one of these.” Dr. Akpek said you won’t see much
staining in early stages of DED. By the time these
stains highlight unhealthy areas of the cornea or the
conjunctiva, the disease is moderate to advanced.
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Treatment
Treatment for both mild evaporative and aqueous
deficient dry eye is relatively straightforward, but it’s
worth keeping a few things in mind.
For evaporative dry eye, the experts recommend
the following.
• Warm compresses. Warm compresses and eyelid
hygiene improve meibomian gland function. Moist
compresses are better than dry heat, Dr. Massaro-­
Giordano said. Hygiene entails removing any makeup, then gently
scrubbing eyelashes
and eyelids with a
commercially available premoistened
pad. (Diluted baby
shampoo or gentle face wash also
works.) Apply mild
pressure along the
rims of the eyelids
in order to express some “oil”
Preservative-free
glaucoma drops are
from the meibomian glands.
advised for dry eye
Then rinse off and pat dry, she
patients.
said.
• Manage the environment.
“Recognition of the environment as a cause of dry eye
can make a huge difference for the patient,” Dr. Feder
said. Prolonged visual effort—reading, watching TV,
computer work—reduces the blink rate, causing desiccation of the ocular surface. Other environmental
causes of drying are fans, car vents, circulating airplane air, and drafts from air conditioners. Patients
may improve in summer and get worse in winter.
“Desktop humidifiers are becoming increasingly
popular,” said Dr. Feder. He added that if the patient
can’t change the environment, eye protection such as
moisture chamber glasses—which have side shields to
keep the eyes’ moisture in—may be helpful.
• Beware of eyedrops. Preservatives in glaucoma medications can destabilize the tear film. Dr.
Massaro-­Giordano advises working with the glaucoma specialist for a preservative-free option. If that’s
not possible, she suggests considering surgery that
cour tesy of giacomina massaro-giordano, md; american academy of ophthalmology
Dr. Massaro• Do you have dry mouth?
Gum disease? These symptoms Giordano squeezes
may be associated with system- a patient’s meibomian glands.
ic disease like Sjögren’s.
Look. Though tests will
confirm the diagnosis, Dr. Weisenthal said he often
knows the results before doing them. “You can tell by
looking at the patient.” He advises checking for the
following:
• Rosacea in the face and eyelids. Rosacea is associated with meibomianitis and evaporative dry eye.
• Look at the lids. Are they floppy? Floppy eyelid
syndrome can cause symptoms of dry eye.
• Red lid margins. This suggests meibomian gland
dysfunction. Press on the lids. If there’s a toothpaste-like secretion or no secretion, the glands are
blocked.
• Watch how often the patient blinks. The norm is
12 blinks per minute. The patient who doesn’t blink
for 30 seconds has a problem.
• Is there an incomplete blink? This is often seen after blepharoplasty.
• Malpositioned lids. Eyelids that are turned in or
out may evert the lacrimal punctum.
• Swelling of the conjunctiva. This may indicate conjunctivochalasis.
Test. Dr. Feder said that by performing the following, “you would miss very few cases of dry eye.”
• Slit-lamp exam to evaluate the tear film. “A tear
meniscus on the inferior lid should be a certain thickness and the fluid should be clear. Some patients have
cellular debris or mucus within
that tear film that just is not
healthy,” Dr. Weisenthal said.
• Schirmer test with anesthetic to measure basal tear
production.
• Fluorescein staining to
Schirmer’s test.
test for tear film breakup time
(TBUT), which is defined as the interval between the
last complete blink and the first appearance of a dry
spot or disruption in the tear film. Once in the tear
film, fluorescein should stay intact for at least 10 seconds. This test provides evidence of tear film stability,
which suggests how well the meibomian glands are
reduces the need for glaucoma medications.
• Recognize systemic medication effects. Anticholinergics, antidepressants, or oral allergy and decongestant medications designed to dry up mucous
membranes all can dry the surface of the eye, Dr.
Feder said. Dr. Massaro-Giordano noted that a lot of
patients have itchy lids resulting from advanced anterior blepharitis. “They get an over-the-counter allergy
drug, which in turn dries them out further.”
For aqueous tear deficiency, the experts recommend the following.
• Artificial tears. For mild cases, Dr. Weisenthal
gives patients two or three samples to try. “People
seem to have their favorite.” The experts agreed that
anyone using tear supplements more than four times a
day should use preservative-free varieties.
• Anti-inflammatory agents. For moderate to severe
cases of dry eye, a mild topical steroid may help. Dr.
Weisenthal starts with steroids four times a day for
two weeks and tapers to twice a day for two weeks. No
more than two to four weeks of treatment is recommended, Dr. Weisenthal warned.
Topical cyclosporine (Restasis) has anti-inflammatory properties without the side effects associated
with steroids. But it can take time for increased tear
production to kick in. For immediate relief, Dr. Weisenthal prescribes a steroid (as above) for four weeks.
By then the cyclosporine kicks in, and he stops the
steroids.
Restasis benefits many, but not all, patients. “It’s
not particularly helpful for evaporative dry eye,” Dr.
Feder said. “Its greatest utility is for patients with connective tissue disease who have inflammation of the
lacrimal glands.”
• Punctal plugs. For moderate to severe cases of dry
eye, Dr. Feder prefers punctal plugs to cautery because
they’re reversible. But in cases of severe dry eye associated with a chronic systemic disease, such as rheumatoid arthritis, he’ll consider cautery. “If you’re going
to use punctal plugs, put in the largest plug possible
because it’s more likely to stay in.”
Dr. Weisenthal considers plugs as an alternative to
long-term Restasis for patients with ATD. He warned
that using plugs in
cases of meibomian
gland dysfunction
will sometimes
make the condition
worse.
• Omega-3. When
she heard reports
that omega-3
Silicone punctal plug.
“works great” for
dry eye disease, Dr. Asbell went to the literature. The
data were limited to a few small trials, all using different types and amounts of omega-3s and different
endpoints, she said. “We needed a real trial.”
That trial is now under way. DREAM (Dry Eye
Evaluation and Management) is the first clinical trial
for dry eye funded by the NEI. Six hundred patients
at 21 sites across the United States will be randomized
into two groups to determine whether oral supplementation with omega-3s is an effective treatment for
dry eye disease compared with placebo. DREAM will
also assess potential biomarkers for inflammation.
When to refer. All of the experts agreed that some
cases require specialized care. Dr. Massaro-Giordano
recommended referral to an academic center with an
interest in DED or to a doctor who deals in surface
rober t w. weisenthal, md
PEARLS from the experts
Academy guidelines. “Review the Academy’s Dry
Eye Syndrome Preferred Practice Patterns. The evidence-based information has been carefully reviewed
by a panel of experts. It’s a great resource. It’s easily
accessible. And it’s free.” —Dr. Feder
Find the guidelines at www.aao.org/ppp and scroll to Dry
Eye Syndrome PPP - 2013.
Artificial tears. “Not all artificial tears are the
same. They have different consistencies. Although
there can be some trial and error, it’s worth taking a
look at some of the newer artificial tears. Some drops
are geared more toward lipid abnormality, others toward
mild lubrication. And some are more long-lasting.”
—Dr. Asbell
Examining the eyelids. “Look at those lids! Put pressure up against the eyelid with a fingertip or cotton
swab. See what’s coming out. Is it granular? Opaque?
If it’s tough to get out, you
know you have a problem.”
—Dr. Massaro-Giordano
Patient expectations.
“Dry eye is not something
you can treat for two months
and it will go away. It can
be controlled, but it’s not
something that disappears.
So it’s important to set up expectations so the patient
understands this is something they need to pay attention to and will have to continue to manage.”
—Dr. Weisenthal
Sjögren syndrome. “One main objective in seeing
any dry eye patient is to ask: Is this the 1 in 10
that has Sjögren’s? Dry eye doesn’t kill anyone, but
Sjögren’s can.” —Dr. Akpek
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disease. Because of the multifactorial nature of the
disease, a team approach can be very helpful.
Bottom line. Our understanding of DED has advanced since the days of the watering can. Now it’s up
to the ophthalmologist to apply what’s been learned.
Success with these patients, said Dr. Feder, “really
starts with your curiosity, a careful evaluation, and
then going beyond treating all dry eye symptoms the
same way.” n
1 Schiffman RM et al. Ophthalmology. 2003;110(7):1412-1419.
2 Asbell PA, Spiegel S. Eye Contact Lens. 2010;36(1):33-38.
3 Nichols KK et al. Invest Ophthalmol Vis Sci. 2011;52(4):19221929.
MEET THE EXPERTS
Esen K. Akpek, MD Professor of ophthalmology and
rheumatology and director of the Ocular Surface and
Dry Eye Disease Clinic, Wilmer Eye Institute, Baltimore.
Financial disclosure: Consults for Nicox and has an institutional research grant from Allergan.
Penny A. Asbell, MD, FACS, MBA Professor of ophthalmology and director of the cornea service and refractive
surgery center at Icahn School of Medicine at Mount
Sinai Hospital, New York. Financial disclosure: Conducts
research with Alcon and Rtech Laboratories and is funded
by the NEI for the DREAM study.
Robert S. Feder, MD, MBA Professor of ophthalmology
and chief of cornea/external disease service at North-
Comprehensive Ophthalmologist
Chicago’s Northern Suburbs
NorthShore University HealthSystem (NorthShore), the principal
academic affiliate of the University of Chicago Pritzker School of
Medicine, seeks an exceptional Comprehensive Ophthalmologist.
The successful candidate for this position will be BC/BE by the
ABO and have completed an Ophthalmology residency.
Take advantage of this unique opportunity to:
•Workinoneofthelargestmulti-specialtyophthalmology
groups on the NorthShore!
•Becomeamemberofan870plusphysician,multispecialty
group practice that includes more than 125 office locations with
over2,100affiliatedphysicians.
•BepartoftheMayoClinicCareNetwork;Mayo’sonly
collaboration of its kind in the Chicago region.
•Enjoythefullrangeoflifestylesthatareuniquelyavailableinthe
Chicagoland area.
•AcademicappointmenttoTheUniversityofChicagoPritzker
School of Medicine is available to qualified candidates.
Qualified candidates should submit their CV to: Marian Macsai, MD,
Division Head, Division of Ophthalmology by contacting:
Sandra Chavez
Physician Recruiter
[email protected] • (847) 663-8649
www.northshore.org/physicianrecruitment
western University, Feinberg School of Medicine, Chicago. Financial disclosure: None.
Giacomina Massaro-Giordano, MD Associate clinical
professor of ophthalmology at University of Pennsylvania
Scheie Eye Institute and codirector of the Penn Dry Eye
and Ocular Surface Center, Philadelphia. Financial disclosure: Commercial interest in Physicians Recommended Nutriceuticals.
Robert W. Weisenthal, MD Clinical professor of ophthalmology, SUNY Upstate Medical University, Syracuse,
N.Y. Financial disclosure: None.
The 13th Annual Downeast
Ophthalmology Symposium
SEPTEMBER 19-21, 2014
Bar Harbor, Maine
For further information,
contact:
Shirley Goggin
Maine Society of
Eye Physicians and Surgeons
P.O. Box 190
Manchester, ME 04351
207-445-2260
[email protected]
EOE: Race/Color/Religion/Sex/National
Origin/Protected Veteran/Disability,
VEVRRA Federal Contractor
www.maineeyemds.com
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